Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Port Arthur Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a suprapubic catheter and multiple comorbidities was on Enhanced Barrier Precautions (EBP), with orders and a care plan requiring staff to wear gown and gloves for high-contact care and to follow infection control procedures. A CNA entered the room without a gown, donned gloves without hand hygiene, handled and emptied the catheter bag that had been on the floor, then returned it to the floor and later placed it on the resident’s bed without sanitizing it or changing the bag or linens. The CNA used the same pair of gloves for incontinent care and dressing and did not perform hand hygiene after care, contrary to facility policy and stated expectations of the charge nurse and DON regarding hand hygiene, PPE use, and proper catheter bag handling.
A resident with severe cognitive impairment and an indwelling suprapubic catheter had a documented physician order for a 16 FR/30 ml catheter with statlock securement, but surveyors observed an unsecured 18 FR/30 ml catheter in place and no leg securement device. MAR review showed an LVN had recorded changing the catheter to a 16 FR/30 ml, yet the catheter present did not match the order. Interviews with an LVN, the ADON, and the DON revealed they were unaware the catheter was unsecured and the wrong size was in use, despite facility policy requiring catheter securement and nursing responsibility to verify and correctly implement catheter orders.
A resident with schizoaffective disorder, post-stroke aphasia and dysphagia, anxiety, seizures, and severely impaired cognition had a documented history of physical aggression and required extensive assistance with ADLs and mobility. Two separate incidents occurred in which this nonverbal resident hit another resident, once in a hallway and once involving a roommate, with staff separating the residents, assessing for injury, initiating short-term behavior monitoring, and notifying appropriate authorities. Despite these events and discussion of the incidents in morning meetings, the IDT did not revise the comprehensive care plan to reflect the new resident-to-resident incidents or add specific updated interventions, and no new interventions had been added to the care plan for an extended period. The MDS coordinator later acknowledged forgetting to update the care plan, and leadership confirmed there was no facility-specific policy for care plan revision beyond following the RAI Manual.
A resident with neuromuscular bladder dysfunction and severe cognitive impairment was found with an unsecured Foley catheter, despite physician orders and facility policy requiring securement. Nursing staff acknowledged responsibility for ensuring catheter securement but failed to do so, resulting in noncompliance with established protocols.
A nurse left a medication cart unlocked and unattended in a hallway, making medications accessible to unauthorized individuals. The cart contained various medications, including controlled substances, and was out of the nurse's line of sight. Facility policy and staff interviews confirmed that medication carts are required to be locked and supervised at all times.
Two shower rooms were found with soiled equipment, including shower chairs with brown and black substances and a shower bed with a thick black coating under the cushion. Staff interviews revealed that cleaning protocols requiring aides to clean equipment before and after each use were not consistently followed, and equipment was not always cleaned according to facility policy.
Surveyors found that medication and treatment carts were repeatedly left unlocked and unsupervised, containing various medications and supplies labeled as 'keep out of reach of children.' Additionally, a nurse cart contained loose pills and an opened Basaglar insulin pen without a date of opening. Staff interviews confirmed that these practices were against facility policy, which requires all medications to be securely stored and properly labeled.
Multiple residents experienced verbal and physical abuse from other residents, including incidents where a resident with dementia was slapped, a resident with anxiety was verbally abused, a resident with bipolar disorder was physically shaken, and a resident was struck after a wheelchair collision. Despite care plans addressing behavioral risks and interventions, these abusive events were not prevented, indicating a failure to protect residents from abuse as required.
Two residents did not receive care as ordered by their physicians: one did not receive newly prescribed Depakote for mood stabilization due to missed doses and lack of documentation, while another did not have a urine specimen collected for a UTI Panel before starting antibiotics, as required. These failures were due to lapses in staff communication, documentation, and timely execution of orders.
A resident with severe cognitive impairment was incorrectly documented as having side rails or restraints on the MDS assessment, despite no such devices being present or ordered. Staff interviews and record reviews confirmed the error was due to an accidental marking by the MDS Nurse, and the resident's care plan and actual care did not include side rails or restraints.
A resident with a history of mental illness and psychotropic medication use was readmitted from a mental health hospital, but the required PASRR Level 1 screening was not properly submitted, and no Level II evaluation was completed. The MDS nurse responsible for PASRR forms acknowledged the oversight, and the DON confirmed the lapse in procedure, resulting in missing documentation and evaluation for the resident.
A resident with multiple medical conditions did not receive the prescribed dose of vitamin C due to a medication administration error by an LVN, who gave only one tablet instead of the ordered two. Additionally, three aspart insulin pens remained on a medication cart beyond the recommended 28-day use period, as nursing staff failed to remove them as required. Facility policies for medication administration and removal of expired drugs were not followed, leading to these deficiencies.
A resident with hypertension received Metoprolol and Hydralazine despite blood pressure and heart rate readings that were outside the physician-ordered parameters. Facility staff, including an LVN, confirmed the medications were given in error, and the DON and administrator stated that medications should be administered according to orders. Facility policy required adherence to prescriber instructions.
The facility did not notify physicians when two residents experienced missed or delayed treatments. One resident did not have a urine specimen collected for a UTI panel before starting antibiotics, and the physician was not informed. Another resident missed two doses of a newly prescribed medication for mood, and the physician was not notified of the missed doses. Nursing and administrative staff confirmed these lapses in communication.
A resident with a tracheostomy did not receive a scheduled outer cannula change as ordered by the physician, and there was no documentation of the procedure being performed on the medication administration record. Interviews with the ADON, DON, and the LVN responsible confirmed the lack of documentation and indicated the procedure was not completed as required by facility policy.
A resident with multiple health conditions, including morbid obesity and muscle weakness, who required two-person assistance for bed mobility, was left unsupervised by a single CNA during incontinent care. This resulted in the resident sliding off the bed and sustaining an acute distal femur fracture, requiring hospitalization and surgery. Documentation and staff interviews confirmed that the need for two-person assistance was clearly indicated in the care plan and Kardex, but the protocol was not followed.
A resident with a history of mental health and substance use disorders reported to the admission coordinator that a CNA was verbally and physically aggressive and prevented him from calling the police. The admission coordinator did not immediately report the allegation to the abuse coordinator or administrator, resulting in a delay in notifying authorities beyond the required two-hour timeframe. Staff interviews confirmed the delay, and facility policy requiring immediate reporting was not followed.
Two residents received wound care without proper adherence to enhanced barrier precautions, including failures by nursing staff to wear required PPE, perform hand hygiene at appropriate times, and handle wound care supplies according to infection control protocols.
A resident with a history of schizophrenia and aggressive behavior repeatedly assaulted other residents, resulting in injuries. The facility failed to implement adequate supervision or specific interventions to prevent further incidents, despite being aware of the resident's tendencies. Staff interviews revealed a lack of awareness of monitoring requirements, contributing to the failure to protect residents from harm.
A facility failed to investigate and report an incident where a resident with severe cognitive impairment slapped another resident, causing injury. Despite the incident being reported to administration and medical staff, no investigation report was submitted to the State Survey Agency within the required timeframe, potentially placing residents at risk of further abuse.
The facility failed to notify the physician of changes in condition for two residents. One resident had multiple instances of elevated blood pressure, and another had her medication held due to low pulse readings. In both cases, the physician was not consulted, contrary to facility policy.
The facility failed to protect two residents from abuse. A resident with schizoaffective disorder was verbally abused by a CNA, who unplugged the facility phone and called her derogatory names. Another resident with Alzheimer's was physically abused by his roommate, who grabbed his arm, causing redness. Both incidents were not promptly reported to the appropriate authorities, violating the facility's policies.
The facility failed to implement policies to prevent abuse, neglect, and exploitation for three residents. One resident experienced verbal abuse from a CNA, another was physically aggressed by a roommate, and a third resident with a history of aggression was involved in the incident. Reporting of these incidents was delayed, contrary to facility policy.
The facility failed to report alleged abuse incidents involving three residents to the administrator and State Agency within the required 2-hour period. Incidents included verbal abuse by a CNA and physical altercations between residents. The delays in reporting violated facility policies and state regulations.
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in documenting special treatments and procedures. One resident with quadriplegia and tracheotomy status did not have her tracheostomy care accurately reflected in her MDS assessment, while another resident with chronic kidney disease and dependence on renal dialysis did not have his dialysis treatments documented. The deficiencies were attributed to oversight and lack of a double-check system.
The facility failed to trim the fingernails of a resident with severe cognitive impairment and contractures, despite care plans and policies requiring regular nail maintenance. Staff acknowledged the oversight, and the resident expressed a desire to have his nails cut.
A resident with hemiplegia/hemiparesis and stroke did not receive the ordered resting hand splint to treat and correct contracture. Observations and staff interviews revealed that the splint was not applied as required, and the resident's care plan and TARs did not reflect the necessary interventions. This failure placed the resident at risk of further contractures and decreased range of motion.
A resident with multiple health conditions, including atrial fibrillation and morbid obesity, was observed receiving oxygen at 3 liters per minute instead of the prescribed 2 liters. Despite the physician's order and the facility's Oxygen Administration policy, staff failed to administer the correct dosage, potentially risking the resident's health.
A facility failed to document BP and HR before administering metoprolol tartrate to a resident with hypertension, despite prescribed parameters. Staff interviews and record reviews revealed an oversight in the system and failure to trigger necessary documentation, leading to a significant deficiency in medication administration procedures.
A resident with hypertension and heart failure was administered metoprolol tartrate despite having a pulse below the prescribed parameters on three occasions. The facility's policy on medication therapy was not followed, leading to the administration of the medication contrary to the physician's orders.
The facility failed to employ a qualified social worker on a full-time basis for approximately six months, relying instead on a part-time social worker who worked as needed and on some weekends. Despite efforts to hire a full-time social worker, the position remained unfilled, which was confirmed through interviews with HR staff, the part-time social worker, and the Administrator. The facility has a licensed capacity of 199 beds, necessitating a full-time social worker.
The facility failed to provide mandatory QAPI training to eight staff members, including the Dietary Supervisor, ADON, LVNs, Laundry Supervisor, and CNAs, as required. Record reviews and interviews revealed that these staff members had no documented QAPI training, despite the Administrator's expectation that such training was included in the computerized training system and in-service orientation.
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for four residents. This included missing documentation for wound care and weekly skin assessments on specific dates, leading to incomplete or inaccurate records and inadequate care.
The facility failed to provide necessary behavioral health services to a resident after his return from a behavioral health hospital. Despite the need for follow-up psychiatry services, no psychiatric assessment or behavior monitoring was conducted. The resident had been involved in an altercation and exhibited aggressive behavior, but the facility did not update his care plan or ensure he received the required services.
A resident who required two-person assistance for bed mobility fell and sustained a scalp hematoma when a CNA provided incontinent care alone, contrary to the care plan. The CNA did not check the Kardex or request help from available staff, leading to the incident.
Failure to Follow Enhanced Barrier Precautions and Catheter Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP) related to a suprapubic catheter. The resident was an adult male with hemiplegia and hemiparesis of the left non-dominant side, COPD, a history of UTI, and a bulbar urethral stricture, and had an indwelling catheter. His active orders and care plan required staff to use gown and gloves before room entry and during high-contact care activities, including catheter care, dressing, bathing, hygiene, and toileting, and to follow EBP protocols to prevent infection. During an observation, a CNA entered the resident’s room without wearing a gown or gloves, despite the resident being on EBP. The resident’s suprapubic catheter bag was on the floor near the bed. The CNA donned gloves without performing hand hygiene, picked the catheter bag up from the floor, emptied 580 ml of urine into a urinal, and then placed the catheter bag back on the floor. After discarding the used gloves, the CNA applied a new pair without hand hygiene and proceeded to provide incontinent care and dress the resident using the same pair of gloves. The CNA then picked the catheter bag from the floor and placed it on the resident’s bed to dress him, without sanitizing the bag, changing the bag, or changing the bed linens, and did not perform hand hygiene after completing care. In interviews, the CNA acknowledged she should have worn a gown, kept the catheter bag off the floor on a fixed structure below bladder level, and performed hand hygiene between glove changes and before handling the catheter bag. The charge nurse and DON stated their expectations that staff perform hand hygiene before, between, and after glove changes, keep catheter bags off the floor, and wear gowns and gloves for residents on EBP, consistent with facility policies on catheter care and the infection prevention and control program.
Failure to Secure Suprapubic Catheter and Follow Ordered Catheter Size
Penalty
Summary
Surveyors identified that a resident with neuromuscular bladder dysfunction, quadriplegia, aphasia, tracheostomy, and severe cognitive impairment (BIMS score of 0) did not receive appropriate treatment and services related to an indwelling suprapubic catheter. The resident’s care plan documented an indwelling 18 FR suprapubic catheter with an intervention to ensure a statlock was in place to secure the Foley tubing to prevent injury. The physician’s order summary, however, directed that a 16 FR/30 ml suprapubic catheter be exchanged every four weeks and as needed, and that the suprapubic catheter be secured with a statlock. Record review of the MAR showed that on a specified date at 2:20 a.m., an LVN changed the resident’s suprapubic catheter and documented insertion of a 16 FR/30 ml catheter. During observation later that morning, surveyors noted the resident in bed with the suprapubic catheter unsecured and without a statlock or other leg securement device in place. The catheter in place was labeled 18 FR/30 ml, which did not match the physician’s order for a 16 FR catheter. A subsequent observation confirmed that both 16 FR and 18 FR catheters were available in the facility’s supply room. In interviews, an LVN stated the resident had an order for a 16 FR suprapubic catheter since a specified date but currently had an 18 FR catheter in place, and acknowledged she was unaware the catheter was unsecured and that nurses were responsible for verifying catheter size and securement at the start of their shifts. The ADON confirmed the order for a 16 FR suprapubic catheter, acknowledged that an 18 FR catheter had been placed by an LVN, and stated he was not aware the wrong size catheter was in place. The DON also stated she was not aware the catheter was unsecured or that the wrong size (18 FR instead of 16 FR) had been used, and affirmed that nurses were responsible for verifying and correctly implementing physician orders, including inserting the correct catheter size and securing it. Facility policy on urinary catheter care required that catheters remain secured with a securement device to reduce friction and movement at the insertion site.
Failure to Revise Care Plan After Repeated Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan after significant behavioral incidents, as required. The resident was a female with schizoaffective disorder, cerebral infarction with resulting aphasia and dysphagia, anxiety disorder, seizures, and severely impaired cognition (BIMS score of 00). Her quarterly MDS dated 06/22/2025 showed she was sometimes able to make herself understood, usually understood others, and required moderate to maximum assistance with most ADLs and mobility, using a manual wheelchair with supervision or touching assistance. Her care plan, last revised on 11/03/2025, documented a history of physical aggression toward staff and other residents and included general interventions such as PRN medications, anticipating needs, communication techniques, behavior monitoring, psychiatric consults as indicated, and notification of appropriate authorities. Despite this history and the presence of two documented resident-to-resident incidents, the care plan was not updated to reflect these specific events or any new interventions. On 07/18/2025, progress notes and an incident report authored by an LVN documented that the resident, while in a wheelchair in the hallway, grabbed another resident by the hands and slapped the other resident on the left side of the face. The CNA who witnessed the event immediately separated the residents, and the LVN completed a head-to-toe assessment, pain assessment, and vital signs, with no injuries or pain noted. A provider investigation report dated 07/22/2025 confirmed that the resident hit another resident on the left side of the face/neck, that both residents had no injuries, and that behavioral monitoring was initiated for 72 hours. However, the comprehensive care plan showed no revisions or added interventions related to this incident. A second incident occurred on 08/16/2025, documented in progress notes and an incident report by another LVN. A CNA reported that the resident hit her roommate twice in the chest after an interaction involving the roommate’s bed linens. The residents were separated, both were assessed with no injuries noted, and the resident denied pain by shaking her head. A provider investigation report dated 08/16/2025 confirmed that the resident hit another resident on the chest, that both residents had no injuries, and that behavioral monitoring was again initiated for 72 hours. Interviews with the LVNs indicated that staff viewed the resident’s hitting/patting as a way to gain attention due to her being nonverbal, and that they followed facility protocols for assessment, monitoring, separation, and notification of authorities. Nonetheless, review of the care plan showed no interventions added since 06/17/2024 and no updates to reflect these two resident-to-resident incidents. Interviews with the MDS Coordinator, DON, and Administrator further clarified the inaction that led to the deficiency. The MDS Coordinator stated that incidents and allegations were discussed in morning meetings and that she recalled discussing the July and August incidents involving this resident, believing at the time that the care plan had been updated. She acknowledged that the care plan should have been revised to reflect the resident’s current needs and the interventions used, including monitoring, authority notification, and communication techniques, and admitted she had forgotten to update the care plan. The DON stated that all incidents were discussed in morning meetings, that the MDS Coordinator was responsible for revising care plans, and that new interventions should be added for recurrent resident-to-resident altercations; she did not know why the care plan had not been updated. The Administrator stated that the MDS Coordinator and DON were responsible for ensuring care plans were updated and recognized that failure to revise care plans could result in residents not receiving needed care. Both the DON and MDS Coordinator reported that the facility had no specific policy for care plan updating or revision and that they followed the RAI Manual, which states that significant changes requiring interdisciplinary review and/or care plan revision include major declines or improvements that are not self-limiting and affect more than one area of health status. The combined record review and staff interviews demonstrated that, although the resident experienced at least two documented resident-to-resident physical contact incidents and was placed on behavioral monitoring each time, the interdisciplinary team did not revise the comprehensive care plan to incorporate these events or any specific, updated interventions. The care plan remained unchanged with no new interventions added since 06/17/2024, despite the resident’s ongoing behavioral issues and the subsequent incidents. This failure to update the care plan after each assessment and incident constituted the cited deficiency in care planning for this resident.
Failure to Secure Foley Catheter as Ordered
Penalty
Summary
A deficiency occurred when a male resident with neuromuscular dysfunction of the bladder, who was severely cognitively impaired and required assistance with all activities of daily living, was observed without his Foley catheter being secured to his leg as required. The resident's care plan and physician orders specified that the catheter should be secured with a leg strap and monitored twice daily to prevent catheter-related trauma. On the date of observation, no securement device was present, and the Foley catheter was not attached to the resident's leg. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that it was the responsibility of the nursing staff to ensure the catheter was properly secured according to facility policy and physician orders. The LVN admitted to not checking the securement device at the start of her shift and was unaware that it was missing. Facility policy, revised in August 2022, also required that urinary catheters remain secured to prevent complications. The failure to secure the catheter as ordered and per policy constituted the deficiency.
Medication Cart Left Unlocked and Unattended by Nurse
Penalty
Summary
A deficiency occurred when a nurse failed to secure the Hall 300 medication cart, leaving it unlocked and unattended for approximately five minutes in a hallway. During this time, the cart was positioned with its drawers facing the hallway and the lock mechanism disengaged, making medications accessible to unauthorized individuals. The nurse responsible for the cart admitted to being two rooms away and out of sight of the cart, acknowledging that she forgot to lock it before leaving. Observations revealed that the cart contained glucometers, over-the-counter medications, vitamins, minerals, eye drops, and a locked compartment with controlled substances and resident-specific medication packets. Interviews with the nurse, DON, and Administrator confirmed that facility policy requires medication carts to be locked and within the nurse's line of sight when not in use. The nurse stated she had been trained to keep the cart locked and recognized the risk of leaving it unsecured. The DON and Administrator reiterated expectations that all nursing staff are responsible for securing medication carts to prevent unauthorized access, in accordance with facility policy and procedures.
Failure to Maintain Clean and Safe Shower Equipment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of four shower rooms reviewed. In Hall 300, two shower chairs were observed to be soiled with brown and black substances on the seat, under the seats, and on the frame. Additionally, a section of the shower wall and baseboard was soiled with a black substance. Staff interviews revealed that shower chairs were expected to be cleaned before and after each use by the aides, with cleaning supplies provided and stored securely. However, the presence of soiling indicated that these cleaning protocols were not consistently followed. In Hall 400, a shower bed was found with a thick black substance coating the full length of the white plastic stretcher part under the cushion. Staff acknowledged that the bed needed cleaning, and one CNA reported that she had last used the bed a couple of weeks prior, cleaning only the surface and not removing the cushion to clean underneath. Review of the facility's policy confirmed that reusable resident-care equipment should be cleaned and disinfected between uses and according to manufacturer instructions, but these procedures were not adhered to, resulting in unclean equipment in the shower rooms.
Failure to Secure Medication Carts and Properly Label Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored securely and in accordance with state and federal regulations. On multiple occasions, the medication treatment cart was found unlocked and unsupervised at the main nurse station, containing various medications and treatment supplies labeled as 'keep out of reach of children.' Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the cart should always be locked and that the key was kept in the medication room. Despite this, the cart was repeatedly left unsecured, and staff were unable to identify who last used it. Further inspection of the Hall 400 Nurse Cart revealed four loose pills and an opened Basaglar insulin pen that was not labeled with the date it was first opened. The LVN responsible for the cart acknowledged that staff are expected to check their carts daily for loose pills and ensure all medications are properly labeled and stored in original pharmacy packaging. The DON confirmed that nurses are responsible for keeping medication carts clean, free of loose pills, and for labeling insulin with the date opened. A review of the facility's policy on medication labeling and storage indicated that medications must be stored in their original containers, and all compartments containing medications must be locked when not in use. The policy also stated that only the issuing pharmacy is authorized to transfer medications between containers, and that nursing staff are responsible for maintaining medication storage areas in a clean and safe manner. These observations and interviews demonstrated that the facility did not consistently follow its own policies or regulatory requirements regarding medication security and labeling.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from verbal and physical abuse by other residents, as evidenced by four separate incidents involving different individuals. In one case, a female resident with dementia and severely impaired cognition was slapped in the face by another resident with schizophrenia and vascular dementia while both were in wheelchairs. The care plan for the victim included interventions to assess and document claims of aggression and to separate her from others to ensure safety, but the incident still occurred. The aggressor had a care plan addressing behavioral issues related to schizophrenia, with interventions to protect others and monitor behaviors, yet the physical abuse was not prevented. Another incident involved a female resident with anxiety and depression who was verbally abused by a male resident with a history of traumatic brain injury and behavioral syndromes. The male resident cursed at her and made a distressing comment about her deceased daughter. The care plan for the aggressor acknowledged his potential for verbal and physical aggression and included monitoring and separating him from others, but he was still able to verbally abuse another resident. The victim reported feeling afraid at the time of the incident, although she later stated she felt safe after the aggressor apologized. Additional incidents included a female resident with bipolar disorder being physically grabbed and shaken by the same male resident with behavioral issues, despite staff being present and attempting to intervene. In another case, a female resident who often propelled her wheelchair backward accidentally made contact with a male resident, who then struck her on the arm. Both residents had care plans addressing their behaviors and mobility, but the physical altercation still occurred. These events demonstrate that the facility did not effectively implement measures to prevent abuse between residents, as required by their own policies and care plans.
Failure to Follow Physician Orders for Medication Administration and Laboratory Testing
Penalty
Summary
The facility failed to ensure that services provided or arranged met professional standards of quality for two residents in relation to following physician orders. For one resident with a history of traumatic brain injury, bipolar disorder, anxiety disorder, major depressive disorder, and behavioral syndromes, there was a new order for Depakote 250mg twice daily for mood stabilization following discharge from a psychiatric hospital. The medication was not administered as ordered; the resident did not receive the evening dose on the day of return or the morning dose the following day. Staff interviews revealed confusion regarding the medication order's start date, lack of documentation on the MAR, and a failure to notify the physician of the missed dose. The medication was available in the emergency supply, but it was not given, and the pharmacy had not received a request to fill the medication prior to staff inquiry. For another resident with diagnoses including pyelonephritis, head injuries, and quadriplegia, the physician ordered a UTI Panel to be obtained prior to starting antibiotics. The order was documented, but there was no evidence in the medical record or laboratory results that the urine specimen was collected before the initiation of antibiotics. Staff interviews confirmed that the UTI Panel was not obtained as ordered, and the physician was notified after the fact. The specimen was eventually collected and processed several days later, but not in accordance with the original physician order. In both cases, the facility did not follow physician orders as outlined in the residents' comprehensive care plans. There was a lack of documentation, communication, and timely action by nursing staff, resulting in the failure to administer medication and obtain required laboratory specimens as prescribed.
Inaccurate MDS Assessment for Restraint/Side Rail Use
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, resulting in an incorrect indication that the resident had a restraint or side rail in use. The resident in question was a female with diagnoses of dementia and bipolar disorder, who was severely cognitively impaired and required supervision for mobility. Review of her care plans, physician's orders, and medication administration records showed no documentation or prescription for side rails or restraints. Observations confirmed that the resident did not have side rails or restraints on her bed. Interviews with facility staff, including the LVN, MDS Nurse, DON, and Administrator, consistently confirmed that the resident did not have side rails or restraints. The MDS Nurse acknowledged that the error was due to accidentally marking the side rail box on the MDS assessment. The facility did not have a specific MDS policy but followed the Resident Assessment Instrument (RAI) guidelines. The inaccurate MDS assessment was not reflected in the resident's care plan or actual care provided.
Failure to Submit PASRR Screening After Resident Readmission
Penalty
Summary
The facility failed to accurately submit a PASRR Level 1 (PL1) screening for a resident who was readmitted from a mental health hospital with diagnoses including anxiety, schizophrenia, and depression. Despite the resident's history of mental illness and use of psychotropic medications, there was no evidence of a PASRR Level II screening or Form 1012 in the clinical record following the readmission. The resident's PL1 form indicated a positive result for mental illness, but the required follow-up evaluation by the local mental health authority was not completed. Interviews with facility staff revealed that the MDS nurse, who was responsible for PASRR forms, acknowledged overlooking the transmission of the PL1 form upon the resident's readmission. The DON confirmed that the MDS nurse had been trained on PASRR procedures but failed to complete the necessary steps, resulting in the absence of required documentation and evaluation for the resident after readmission.
Failure to Administer Medications as Ordered and Remove Expired Insulin Pens
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for residents. Specifically, a male resident with multiple diagnoses, including protein-calorie malnutrition, diabetes, and cerebrovascular disease, did not receive his prescribed dose of vitamin C as ordered by his physician. The physician's order required two 500 mg tablets of ascorbic acid to be administered once daily, but only one tablet was given on at least one occasion. The nurse responsible acknowledged the error, stating she missed the correct dosage during medication administration. Additionally, the facility did not ensure the timely removal of expired aspart insulin pens from a medication cart. Three insulin pens were found in use beyond the recommended 28-day period after opening, with one pen expired for 31 days, another for 9 days, and a third for 5 days. Nursing staff were expected to check medication carts daily for expired medications, but these insulin pens were overlooked and remained accessible for use. Interviews with nursing staff and the DON confirmed that the facility's procedures required adherence to prescriber orders and timely removal of expired medications. The facility's policies outlined the need for safe and timely medication administration, including verifying the correct dosage and removing outdated medications. However, these procedures were not followed, resulting in medication errors and the presence of expired insulin pens on the medication cart.
Failure to Hold Antihypertensive Medications per Prescribed Parameters
Penalty
Summary
A deficiency occurred when a cognitively intact female resident with a diagnosis of hypertension received blood pressure medications outside of the prescribed parameters. The resident's physician orders specified that Metoprolol tartrate 25 mg should be held if systolic blood pressure (SBP) was below 100, diastolic blood pressure (DBP) below 60, or heart rate (HR) below 60, and Hydralazine HCL 25 mg should be held if SBP was below 110 or DBP below 60. Despite these clear instructions, medication administration records showed that the resident received Metoprolol and Hydralazine on multiple occasions when her blood pressure and/or heart rate were outside the specified parameters. Interviews with facility staff confirmed that the medications were administered in error. The DON stated that medications should be given according to physician orders, and the administrator expected staff to monitor for accuracy. The nurse involved acknowledged the oversight, attributing it to not paying sufficient attention during medication administration, despite having been educated on the importance of following medication parameters. Facility policy also required medications to be administered as ordered by the prescriber.
Failure to Notify Physician of Missed Orders and Treatment Changes
Penalty
Summary
The facility failed to notify the physician when there was a need to alter treatment for two residents. For one resident, who had diagnoses including pyelonephritis, head injuries, and quadriplegia, a physician ordered a UTI Panel to be obtained before starting antibiotics. The medical record showed that the urine specimen was not collected as ordered, and there was no documentation that the physician was notified of this omission before antibiotics were started. Interviews with nursing staff and administration confirmed that the specimen was not obtained and the physician was not informed prior to initiating treatment. For another resident with a history of traumatic brain injury, bipolar disorder, anxiety, major depressive disorder, and behavioral syndromes, there was a new order for Depakote to be administered twice daily. The resident missed two doses of Depakote due to issues with medication reconciliation and documentation on the MAR. Nursing staff did not notify the physician about the missed doses. The DON confirmed that staff are expected to notify the physician if they are unable to carry out an order, and acknowledged that there was no documentation of physician notification regarding the missed medication.
Failure to Provide and Document Scheduled Tracheostomy Cannula Change
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not receive a scheduled tracheostomy outer cannula change as ordered by the physician. The resident, who had diagnoses including head injuries, quadriplegia, and tracheostomy status, had a physician order for the cannula to be changed monthly on a specific day. Review of the medication administration record (MAR) for the relevant month showed that the cannula change was not documented as completed on the scheduled day or at any other time during the month. Interviews with facility staff, including the ADON, DON, and the LVN assigned to the resident on the scheduled day, confirmed that there was no documentation of the procedure being performed. The LVN stated she may have forgotten to document, but acknowledged that if it was not documented, it was not done. The facility's tracheostomy care policy required that tracheostomy tubes be changed as ordered, at least monthly. The DON confirmed that the expected practice was for staff to provide the required tracheostomy care and that all nurses were trained on this procedure.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who required two-person assistance for bed mobility and incontinent care was left unsupervised by only one CNA during care. The resident, an elderly female with multiple diagnoses including morbid obesity, muscle weakness, dementia, and a history of cerebral infarction, was documented in her care plan, Kardex, and MDS assessments as needing two staff members for bed mobility and transfers. Despite these documented requirements, the CNA proceeded to provide care alone, resulting in the resident sliding off the bed and sustaining a significant injury. The incident took place when the CNA attempted to change the resident's brief without waiting for a second staff member, as required by the resident's care plan and facility protocols. The resident slid off the bed, landing on her feet, but her knees buckled due to her inability to bear weight, and she was guided to the floor. Following the fall, the resident complained of pain in her right knee, and subsequent assessment and x-ray revealed an acute fracture of the right distal femur, necessitating hospitalization and surgical intervention. Interviews and record reviews confirmed that the CNA was aware of the two-person assist requirement but cited staffing shortages as the reason for acting alone. Other staff members and nursing leadership confirmed that the resident's care plan and Kardex clearly indicated the need for two-person assistance for bed mobility and transfers. The failure to follow established protocols and provide adequate supervision directly led to the resident's fall and injury.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by federal regulations. Specifically, a resident with a history of schizophrenia, anxiety, schizoaffective disorder, and substance abuse reported to the admission coordinator that an unidentified CNA was verbally and physically aggressive and that he feared for his safety. The admission coordinator did not immediately report this allegation to the abuse coordinator or the administrator. Record review showed that the resident was cognitively intact and able to make himself understood. The resident alleged that a CNA entered his room, was yelling, being aggressive, would not let him call the police, and yanked the phone out of his hand. The incident was documented in a grievance/complaint report by the admission coordinator, but the administrator and DON were not designated to investigate until the following day. The facility did not report the allegation to the state agency until more than two hours after the admission coordinator was informed, which was outside the required reporting timeframe. Interviews with facility staff confirmed that the admission coordinator received the allegation but did not recall the exact time and did not immediately report it, despite being trained on abuse and reporting requirements. The administrator acknowledged that the delay in reporting placed residents at risk. The facility's own policies required immediate reporting of suspected abuse to the administrator and authorities, but these procedures were not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the implementation of enhanced barrier precautions (EBP) during wound care for two residents. In one instance, a nurse (LVN B) provided wound care to a resident with a deep tissue injury on the right lateral ankle without wearing a gown, as required by EBP protocols. Although hand hygiene was performed and gloves were used, the omission of a gown during the procedure was acknowledged by the nurse, who stated that not wearing a gown could harbor bacteria. In another case, a different nurse (LVN C) performed wound care for a resident with pressure ulcers and moisture-associated skin damage on both heels. While a gown was worn, the nurse failed to follow proper infection control practices, including not performing hand hygiene at critical points, retrieving supplies from her scrub pockets under the gown with potentially contaminated hands, and not cleaning the wound cleanser bottle before returning it to the treatment cart. The nurse also removed her gown outside the room and did not perform hand hygiene before or after leaving the resident's room. Interviews with staff, including the Infection Preventionist, confirmed that the observed practices did not align with facility policy or CDC guidelines for EBP. The facility's infection control policy and CDC resources both require the use of gown and gloves for high-contact care activities and emphasize the importance of hand hygiene and proper handling of supplies. Requested documentation of infection control in-services and policies specific to EBP was not provided prior to the survey exit.
Failure to Protect Residents from Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, specifically failing to prevent a resident from physically abusing other residents. The incidents involved a resident with a history of schizophrenia, OCD, and aggressive behavior, who repeatedly assaulted other residents over several months. Despite being aware of the resident's aggressive tendencies, the facility did not implement adequate supervision or specific interventions to prevent further incidents. The resident in question had a documented history of aggressive behavior, including hitting and pushing other residents, resulting in injuries such as a head laceration that required medical attention. The facility's care plans and interventions were insufficient, lacking specific measures to prevent the resident's aggression towards others. Staff interviews revealed a lack of awareness and understanding of the resident's monitoring requirements, contributing to the failure to protect other residents from harm. The facility's response to the incidents was inadequate, as they did not consistently implement or update interventions to address the resident's behavior. Despite multiple incidents and attempts to find alternative placement for the resident, the facility continued to leave the resident unsupervised, leading to repeated instances of abuse. The facility's policies and procedures for monitoring and managing aggressive behavior were not effectively communicated or enforced among staff, resulting in ongoing risks to resident safety.
Failure to Investigate and Report Resident Abuse Incident
Penalty
Summary
The facility failed to investigate and report the findings of an incident involving two residents to the State Survey Agency within the required 5 working days. On 05/20/24, Resident #6, who has a history of cerebral infarction, hemiplegia, hemiparesis, aphasia, anxiety, and schizoaffective disorder, slapped Resident #7 in the dining room. Resident #6 was described as having severe cognitive impairment and was rarely understood by others. Following the incident, Resident #6 was placed on 1-1 monitoring and later transferred to a behavioral hospital. Resident #7, who has a history of cerebral infarction and depression, was able to make herself understood and was cognitively intact. She reported being hit on the arm by Resident #6, which resulted in active bleeding. The incident was witnessed by a staff member who intervened and separated the residents. Despite the incident being reported to the facility's administration and medical personnel, there was no completed investigation report available for review. The facility's policy requires that all reports of resident abuse be thoroughly investigated and reported to the appropriate agencies within five business days. However, the facility failed to comply with this policy, as there was no investigation report submitted to the State Survey Agency. This failure to investigate and report the incident could place residents at risk of further abuse.
Failure to Notify Physician of Changes in Resident Condition
Penalty
Summary
The facility failed to consult with the resident's physician when there was a need to alter treatment for two residents. Resident #68, a [AGE] year-old female with a history of stroke, schizoaffective disorder, and seizures, had multiple instances of elevated blood pressure that were outside the prescribed parameters. Despite these elevated readings, the physician was not notified, and the resident was administered clonidine without physician consultation. The nurse responsible admitted to not placing the elevated blood pressure readings on the 24-hour report, which was against the facility's expectations for handling such changes in condition. Similarly, Resident #71, a [AGE] year-old female with essential hypertension, had her metoprolol medication held multiple times due to her pulse being below the prescribed parameters. Despite this, there was no documentation indicating that the physician was consulted about the medication being held. The nurse responsible acknowledged the failure to notify the physician, and the Assistant Director of Nursing (ADON) confirmed that the expectation was to consult the physician when medications were held for two consecutive occasions. The facility's policy on medication therapy indicated that physicians should be consulted when medications are given in excessive doses, for excessive periods, or when clinically significant adverse consequences are observed. The failure to notify the physician in both cases could place residents at risk of not receiving appropriate medical treatments, potentially leading to severe illness or hospitalization.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure the rights of residents to be free from abuse or neglect for two residents. Resident #16, a female with schizoaffective disorder, was verbally abused by CNA D. The incident occurred when Resident #16 attempted to use the facility phone, and CNA D unplugged the phone, cursed at her, and called her derogatory names. This incident was witnessed by another CNA, who reported it to the LVN on duty. Despite the immediate report, the LVN failed to notify the Abuse Coordinator until the end of the shift. The facility eventually suspended and terminated CNA D following an investigation that confirmed the abuse allegations. Resident #28, an 85-year-old male with Alzheimer's and dementia, experienced physical abuse from his roommate, Resident #72. The incident occurred when Resident #72, who also had severe cognitive impairments, grabbed Resident #28's arm, causing redness. Staff intervened and separated the residents. Resident #72 was subsequently monitored and moved to another room before being sent to a behavioral hospital. The incident was reported to the ADON, who then reported it to the Abuse Coordinator. The facility's policy required immediate reporting of abuse allegations, which was not adhered to in this case. Both incidents highlight the facility's failure to protect residents from abuse and neglect. The verbal abuse of Resident #16 and the physical abuse of Resident #28 were not promptly reported to the appropriate authorities, as required by the facility's policies. These deficiencies indicate lapses in staff training, supervision, and adherence to abuse prevention protocols, putting residents at risk of further harm.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for three residents. Resident #16 experienced verbal abuse from CNA D, who cursed at her, called her derogatory names, and disconnected the facility phone to prevent her from making a call. This incident was reported late to the Abuse Coordinator, and CNA D was allowed to continue working during the shift. The DON and Administrator were not notified immediately as required by the facility's policy. Resident #28 was subjected to physical aggression from his roommate, who grabbed his right forearm, causing redness. The incident was observed by LVN M, who separated the residents and assessed Resident #28. The care plan for Resident #28 included interventions such as monitoring for pain and notifying the responsible party and hospice. However, the incident was not reported as an allegation of abuse within the required two-hour timeframe. Resident #72, who had a history of physical aggression and severe cognitive impairment, was involved in the incident with Resident #28. He was later transferred to a behavioral hospital. The Administrator and DON discussed the incident and decided it was not an allegation of abuse, leading to a delay in reporting. The facility's policy required any allegations of abuse to be reported within two hours, but this was not adhered to in this case.
Failure to Report Abuse Incidents Timely
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse of residents were reported immediately to the administrator and to HHSC within the 2-hour period for three residents. The first incident involved a verbal altercation between a CNA and a resident, where the CNA cursed at the resident and disconnected the facility phone to prevent the resident from making a call. This incident was not reported to the administrator or the State Agency within the required 2-hour timeframe. The CNA involved was suspended and later terminated, but the delay in reporting was a clear violation of the facility's policies and state regulations. The second incident involved a physical altercation between two residents. One resident grabbed the other's forearm, causing redness and indentations. This incident was also not reported to the administrator or the State Agency within the required 2-hour period. The staff involved in separating the residents and assessing the situation did not follow the proper reporting protocols, leading to a delay in addressing the issue. The third incident involved another physical altercation between two residents, where one resident grabbed the other's arm. The staff did not report this incident to the administrator or the State Agency within the required 2-hour period. The facility's failure to report these incidents in a timely manner could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. The facility's policies and protocols for preventing and identifying abuse were not followed, leading to these deficiencies.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in documenting special treatments and procedures. Resident #21, a female with quadriplegia and tracheotomy status, did not have her tracheostomy care accurately reflected in her MDS assessment. Despite receiving tracheostomy care twice daily, this was not captured in her MDS, which was confirmed by the MDS nurse and the Director of Nursing (DON). The MDS nurse admitted to missing this information and stated there was no backup to double-check her work. Similarly, Resident #40, a male with chronic kidney disease and dependence on renal dialysis, did not have his dialysis treatments documented in his MDS assessment. Although he received dialysis three times a week, this was not recorded in his MDS. The Regional Reimbursement Coordinator and the DON both acknowledged that the dialysis treatments should have been documented. The DON and the Administrator confirmed that the MDS nurse was responsible for the accuracy of all MDS assessments and that the Regional Reimbursement Coordinator was supposed to act as a backup. The failure to document these special treatments and procedures accurately in the MDS assessments was attributed to oversight and lack of a double-check system. The Administrator and the Regional Nurse Consultant emphasized the importance of following the Resident Assessment Instrument (RAI) guidelines to ensure accurate documentation. The deficiencies were identified through observations, interviews, and record reviews, highlighting the need for improved accuracy in resident assessments to ensure proper care and facility compliance.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, the facility did not trim the fingernails of a resident with severe cognitive impairment and contractures in the left hand. The resident, who had a history of hemiplegia/hemiparesis and a stroke, required partial/moderate assistance with personal hygiene. Despite care plans indicating the need for staff to check and trim the resident's nails on bath days and as necessary, observations over several days showed that the resident's fingernails were approximately 1/4 inch past the tips of the fingers and thumbs on both hands. The resident expressed a desire to have his nails cut, and staff members acknowledged that the nails were too long and needed trimming. Interviews with staff, including CNAs and the Director of Nursing (DON), confirmed that the resident's nails were not being maintained as required. The DON stated that the expectation was for staff to keep the resident's nails trimmed to prevent potential negative outcomes such as scratching or skin tears. The facility's policy on Activities of Daily Living (ADLs) indicated that residents unable to carry out ADLs independently should receive services to maintain good grooming and personal hygiene, which was not adhered to in this case.
Failure to Provide Appropriate Range of Motion Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Resident #20, who had diagnoses of hemiplegia/hemiparesis and stroke, was ordered to receive a resting hand splint for the left hand and wrist to treat and correct contracture. However, the resident did not have the splint applied as ordered, and the care plan did not include interventions for the splint. Additionally, the resident's Treatment Administration Records (TARs) for April and May 2024 were blank and did not indicate that the splint was provided as treatment. Observations confirmed that the resident did not have the splint in place during multiple instances over several days, and interviews with staff revealed a lack of awareness and adherence to the physician's orders regarding the splint application. During observations and interviews, it was noted that Resident #20's left hand was severely contracted, and the resident expressed a desire to have his fingernails cut, as they could potentially cut into his skin. The resident mentioned that the splint was applied only sometimes, and staff interviews revealed inconsistencies in the application of the splint. The Restorative Aide (RA) and Occupational Therapy Assistant (OTA) both indicated that the resident had not been seen for range of motion exercises as frequently as required, and the splint was kept in the therapy office rather than being readily available for use. The Director of Therapy and the Director of Nursing (DON) acknowledged that the splint should have been in place as ordered and that the failure to apply the splint could lead to further contractures and a decrease in range of motion. The facility's policy on range of motion indicated that residents with limited range of motion should receive appropriate treatment and services to increase or prevent further decrease in range of motion, which was not followed in this case. This deficiency placed the resident at risk of not receiving the necessary care to maintain their highest level of well-being.
Failure to Administer Correct Oxygen Dosage
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not administer oxygen at the prescribed 2 liters per minute via nasal cannula for a resident with diagnoses including atrial fibrillation, morbid obesity, and tobacco use. Instead, the resident was observed receiving oxygen at 3 liters per minute on multiple occasions, contrary to the physician's order. The resident, who was bedfast and required a Hoyer lift for transfers, was unable to adjust the oxygen dosage independently. The discrepancy was noted during several observations and confirmed by both the LVN and ADON, who acknowledged the error and its potential negative outcomes, such as lung damage and carbon dioxide buildup. The resident's medical records, including the most recent quarterly MDS assessment and care plans, indicated the need for oxygen administration due to conditions like CHF and sleep apnea. Despite these documented needs and the physician's order, the facility staff failed to adhere to the prescribed oxygen dosage. The DON also confirmed that the nurses were expected to follow the orders and ensure the correct oxygen dosage was administered. The facility's Oxygen Administration policy, revised in October 2010, was not followed, leading to the resident receiving an incorrect oxygen dose, which could have serious health implications.
Failure to Document Vital Signs Before Administering Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not documenting blood pressure (BP) or heart rate (HR) before administering medications with specific parameters. This deficiency was identified for a resident with a diagnosis of hypertension who was prescribed metoprolol tartrate with instructions to hold the medication if BP or HR fell below certain levels. Despite the resident's condition and the prescribed parameters, the facility did not document the necessary vital signs on multiple occasions before administering the medication, as evidenced by the Medication Administration Record (MAR) and nurses' notes review. Interviews with the staff, including the Licensed Vocational Nurse (LVN), Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Staffing Coordinator, revealed that the BP and HR were not documented due to an oversight in the system and failure to trigger the necessary documentation. The LVN admitted to checking the resident's BP and HR but failing to document it, while the DON and ADON acknowledged the responsibility of ensuring proper documentation and auditing the charts. The Staffing Coordinator also admitted to not rechecking the orders for accuracy after adjusting the medication administration times. The deficiency was further confirmed by the facility's policy on medication administration, which mandates the documentation of vital signs when necessary. The failure to document BP and HR before administering metoprolol tartrate, as prescribed, was a significant oversight that could potentially lead to adverse effects for the resident. The staff interviews and record reviews highlighted a lapse in following the established procedures for medication administration and documentation, leading to the identified deficiency.
Failure to Hold Medication as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #71's drug regimen was free from unnecessary drugs. Specifically, the facility did not hold the administration of metoprolol tartrate when the resident's heart rate was outside the parameters set by the physician. Resident #71, a [AGE] year-old female with diagnoses including essential hypertension and heart failure, was prescribed metoprolol tartrate with instructions to hold the medication if the systolic blood pressure (SBP) was below 100, diastolic blood pressure (DBP) was below 60, or pulse was below 60. Despite these instructions, the medication was administered on three occasions when the resident's pulse was below the prescribed threshold: on 05/3/24 with a pulse of 47, on 05/9/24 with a pulse of 57, and on 05/10/24 with a pulse of 52. This was confirmed during an interview and record review with ADON A, who acknowledged that the nurses documented heart rates outside the prescribed parameters and still administered the medication, contrary to the physician's orders. The facility's policy on medication therapy emphasized the importance of tapering, discontinuing, or changing medications when given in excessive doses or without adequate monitoring, which was not adhered to in this case.
Failure to Employ Full-Time Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for approximately six months, from November 2023 to May 2024. During this period, the facility only had a social worker who worked on an as-needed basis and some weekends. Interviews with HR staff and the part-time social worker confirmed that the facility had been searching for a full-time social worker but had not yet hired one. The Administrator acknowledged the need for a full-time social worker due to the facility's licensed capacity of 199 beds, but efforts to fill the position had been unsuccessful. This deficiency was identified through interviews and record reviews conducted by surveyors.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that mandatory Quality Assurance and Performance Improvement (QAPI) training was provided to eight staff members, including the Dietary Supervisor, ADON W, LVN T, LVN U, Laundry Supervisor, CNA E, CNA X, and CNA V. Record reviews indicated that these staff members, hired between 1989 and 2022, had no documented QAPI training up to the date of the survey. This lack of training was confirmed through interviews with the HR representative and the Administrator, who acknowledged the oversight and stated that QAPI training was expected to be part of the computerized training system and in-service orientation for new hires. The HR representative admitted to not being informed of the new QAPI training requirement, while the Administrator expressed that she had conducted in-service training on QAPI during orientation for new hires since her tenure. Despite these expectations, the training records did not reflect compliance with the QAPI training requirement, potentially placing residents at risk due to staff not being adequately informed about the QAPI program and its goals.
Failure to Document Wound Care and Skin Assessments
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for four residents. Specifically, the facility did not document weekly wound assessments and ordered wound care for Resident #1, Resident #4, Resident #5, and Resident #6. This included missing documentation for wound care on specific dates and the absence of weekly skin assessments for multiple weeks. The lack of documentation could lead to incomplete or inaccurate records and inadequate care for the residents involved. Resident #1 had a trauma wound on the left inner ankle, and the facility failed to document weekly wound assessments and ordered wound care on several specified dates. The resident's care plan did not address the assessment, care, and treatment of the wound. During an interview, the resident mentioned that wound care was provided daily but had been missed a few times. The treatment nurse confirmed that wound care was provided but admitted to possibly forgetting to document it in the electronic medical records. Resident #4 had multiple pressure injuries and the facility failed to document weekly wound assessments and ordered wound care on several specified dates. The treatment nurse and other staff members confirmed that wound care was provided but admitted to possibly forgetting to document it. Resident #5 had a stage 3 pressure ulcer on the left buttock, and the facility failed to document weekly wound assessments and ordered wound care on several specified dates. The resident mentioned that wound care was provided daily, but the treatment nurse admitted to possibly forgetting to document it. Resident #6 had potential skin integrity issues, and the facility failed to document weekly skin assessments for multiple weeks. The treatment nurse confirmed that skin assessments were performed but admitted to possibly forgetting to document them in the electronic medical records.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to Resident #2 after his return from an inpatient stay at a behavioral health hospital. Resident #2 had been admitted to the behavioral health hospital following a resident-to-resident altercation involving aggressive behavior. Despite the discharge paperwork indicating the need for follow-up psychiatry services, the facility did not conduct a psychiatric assessment or initiate behavior or mood monitoring for Resident #2 upon his return. This oversight persisted from his return on 02/23/2024 until the survey date on 04/16/2024. Resident #2, who has diagnoses including Major Depressive Disorder, Impulse Disorder, and Anxiety Disorder, was involved in an altercation with Resident #3 over a pair of pajama pants. During the incident, Resident #2 exhibited aggressive behavior by rolling towards Resident #3 with a fork in his hand and later being found with a pair of scissors. Despite these behaviors, the facility did not update Resident #2's care plan to reflect his potential risk for aggression or behaviors, nor did they ensure he received the necessary behavioral health services upon his return. Interviews with facility staff, including the MDS Coordinator, LVN, and DON, revealed that they were aware of the altercation and the need for a psychiatric assessment for Resident #2. However, no such assessment was conducted, and no behavioral monitoring was initiated. The facility's policy on Behavioral Assessment, Intervention, and Monitoring, which mandates providing behavioral health services to maintain residents' highest practicable physical, mental, and psychosocial well-being, was not followed in this case.
Inadequate Supervision Leading to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was totally dependent on two staff members for bed mobility, transfers, and toilet use. On the date of the incident, a CNA provided incontinent care to the resident without assistance from another staff member, which resulted in the resident rolling off the bed and sustaining a small left anterior frontal scalp hematoma. The resident was transferred to the hospital for evaluation and treatment, where a CT scan showed no irregularities, and the resident was later returned to the facility. The resident's care plan and Kardex clearly indicated that she required the assistance of two staff members for bed mobility and other activities of daily living. Despite this, the CNA proceeded to provide care alone, stating that she did not see any available CNA to ask for assistance and did not check the Kardex to verify the required level of care. The CNA mentioned that during her orientation, she was told by another CNA that if she felt comfortable, she could perform the resident's care by herself. Interviews with the facility's administrator and other staff members revealed that the CNA did not follow the care guide on the resident's Kardex, and there was no reason for her to provide care without a second staff member as the facility was not short-staffed. The administrator confirmed that all staff were trained during orientation to follow the Kardex care guide, but the incident highlighted a lapse in adherence to this protocol. The facility's investigation report and staff interviews corroborated that the CNA did not request assistance from other available staff members, leading to the resident's fall and injury.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 161 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Port Arthur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sabine Heights Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 15 | 0 |
| Magnolia Manor | 3.6 mi | ★★★★★ | 2 | 0 |
| Bonne Vie | 4.5 mi | ★★★★★ | 7 | 0 |
| Oak Grove Nursing Home | 5.2 mi | ★★★★★ | 0 | 0 |
| Oakwood Manor Nursing Home | 11.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.